venous dz Flashcards
risk factors for venous dz
o Prior ulcers o Smoking o Oral contraceptives/estrogen replacement o Genetics o Obesity o DVT " destined to have venous dz o Trauma o Prolong standing o Pregnancy o Advancing age
CEAP stands for
clinical
etiology
anatomy
pathophysiology
etiology categories
o c = congenital (i.e. Klippel Trenaunay syndrome)
o p = primary (i.e. valve degeneration)
o s = secondary (i.e. post-thrombotic/trauma)
clinical classification
o 0 = no signs of dz o 1 = telangiectasia/reticular eins o 2 = varicose veins o 3 = edema o 4 = pigment/eczema o 5 = healed venous ulcer o 6 = ac ive venous ulcer
anatomy classification
o s = superficial
o p = perforator
o d = deep veins
” P = Pathophysiology: classification
o r = reflex
o o = obstruction
o r, o = reflux & obstruction
Subdermal and intradermal
Up to 50% of population W>M
Reticular veins (spider veins) and telangiectasias
3mm or greater in diameter
Up to 30% of population
Varicose veins
Chronic venous insufficiency
Edema and ulceration
Up to 7 million affected
Superficial veins are superficial to _________
Superficial veins are superficial to the deep muscular fascia
Deep veins are deep to the _______and are either within the ______or between them
Deep veins are deep to the muscular fascia and are either within the muscle or between them
The perforating veins communicate between the ______ and______
The perforating veins communicate between the superficial and the deep venous systems
Superficial venous systemlower extremity
GSV great saphenous vein and small saphenous vein
GSV sometimes is duplicated in the thigh or calf
Popliteal vein becomes the _____ in the______
Popliteal vein becomes the femoral vein in the adductor canal
Profunda femoris vein drains _______ and joins with the ______to become the common femoral vein in the groin
Profunda femoris vein drains lateral thigh muscles and joins with the femoral vein to become the common femoral vein in the groin
these veins connect the superficial with the deep veins (direct perforators)
Perforating veins
Venous _______ are thin-walled and valveless
Located in the calf musculature
Venous sinuses are thin-walled and valveless
Located in the calf musculature
Normal standing pressures are
Normal standing pressures are 90-100mmHg
Calf pump reduces venous pressures by over ____within 10 steps
Calf pump reduces venous pressures by over 70% within 10 steps
Recovery refill after exercises is about ____
Recovery refill after exercises is about 20-70s
Normal displacement _____ of venous blood within the leg to the popliteal vein with each contraction
Normal displacement >60% of venous blood within the leg to the popliteal vein with each contraction
Prolonged hypertension=“
Prolonged hypertension=“leaky capillaries” RBC’s and macromolecules leak, causing inflammatory response into interstitial space Matrix metalloproteinases (MMP’s) and cytokines released which cause tissue fibrosis which impair healing
Patients with superficial venous insufficiency may only be able to reduce pressure by ____
Patients with superficial venous insufficiency may only be able to reduce pressure by 30-40%
Deep venous insufficiency reduction____ with very fast calf refill
Deep venous insufficiency reduction <20% with very fast calf refill
Diagnosing venous diseasePatient history typical sxs
Heaviness, fatigue, pain, itching
Chronic iliofemoral obstruction can result in venous claudication—thigh pain and feeling of tightness with exercise
Leg symptoms are more common in chronic obstruction than in those who have recanalized and have incompetent valves
clinical presentation of venous disease
- – +/- obvious venous bulges
- sx may not correlate well w/ the amount of defect
- Abrasion can lead to impressive bleeding
- Superficial thrombophlebitis relatively common –> can be painful –> rarely leads to PE
- Edema
- Lipodermatosclerosis
- Hyperpigmentation (hemosiderin staining)
- Absence of hair (also seen in PVD)
- Thickened nails
- Varicosities
- Blistering/bullae
Signs of venous insufficiency
Edema Lipodermatosclerosis Hyperpigmentation (hemosiderin staining) Absence of hair (also seen in PVD) Thickened nails Varicosities Blistering/bullae
- Lipodermatosclerosis
hardened skin that can develop with chronic venous insufficiency
Hypoxia in subcutaneous fat
—>hard “woody” induration starts at ankles & progresses proximally
Lipodermatosclerosis
Lipodermatosclerosis presents like a
Inverted champagne bottle or bowling pin appearance
tx for Lipodermatosclerosis
” Avoid BX! í poor healing
“ Stanozol-anabolic steroid w/ fibrinolytic properties helps w/ pain, inflammation & pigmentation
“ Vicki says she does not use this
Hemosiderin Staining
” Valves fail—->regurgitated blood (& venous HTN) force RBC to leak from capillaries
Hemosiderin Staining need to differentiate from
cellulitis
not hot and does not extend
does nothing with abx
venous vs arterial ulcer?
CM of VLU
Generally irregularly shaped, well-defined borders surrounded by erythematous or hyper-pigmented indurated skin
usually found on the ankles
Yellow-white exudate common
Located on lower 1/3 of leg above ankle, MC at medial malleolus —>”gaiter distribution”
NEVER found above the knee & rarely on the foot
Varicose veins & ankle edema are common
physical exam for VLU
Check pedal pulses
ABI (ankle-brachial index test) < 0.70 í consult vascular specialist
Test determined by recording segmental limb pressures
ABI
Normally, ankle pressure should be slightly higher, resulting in an ABI of 1.0 or greater
PVD or PAD indicated if ABI is less than 1.0 (the lower the ABI, the move severe the dz)
arterial ulcers
punched out, well defined, usually on the feet
ABI (ankle-branchial index test) what is it and how do we calculate
allows you to determine where the diseases is
Test determined by recording segmental limb pressures
if less than .70 need to consult vascular
is calculated by dividing the SBP in the ankle by the SBP in the brachial artery in the arm
Normally, ankle pressure should be…
Normally, ankle pressure should be slightly higher, resulting in an ABI of 1.0 or greater
what is indicated with a ABI <1.0
PVD or PAD indicated if ABI is less than 1.0 (the lower the ABI, the move severe the dz)
DDX of VLU
Untreated CHF Lymphedema Arterial dz: ABI Cellulitis: is it hot? DVT: SCC: skin cancer on LE?
Invasive & expensive but GOLD standard for dx VLU
CT &MR venography
CT &MR venography, when do we use
invasive & expensive but GOLD standard
Useful for evaluating central veins which are hard to assess w/ US
Reserved for those needing reconstruction
Anatomic abnormalities - no use in physiologic evaluation
